the breast- lecture 1
TRANSCRIPT
The breastBy
Dr. Imad Wajeh
Introduction
A. Embryologically: belong to integument (skin)
B. Functionally: part of reproductive system
C. Modified apocrine sweat glands - apex of cell becomes part of secretion and breaks off
Embryology
The mammary milk line
Embryology
At the fifth or sixth week of fetal development, two ventral bands of thickened ectoderm (mammary ridges, milk lines) are evident in the embryo. In most mammals, paired breasts develop along these ridges, which extend from axilla to the inguinal area.
Physiology
• The Breast is an apocrine gland modified for the formation of milk under normal physiological circumstances.
• The breast remains undeveloped in the female until puberty, when it enlarges in response to ovarian estrogen and progesterone, which initiate proliferation of the epithelial and connective tissue elements.
Physiology
The breast at different physiological stages. The central column contains three-dimensional depictions of microscopy structures. A. Adolescence. B. Pregnancy. C. Lactation. D. Senescence.
Physiology
• Hormonal Effects– Estrogen
• Development of the breast and lactiferous ducts
– Progesterone• Secretory acinar tissue – lobules
– Prolactin• Synergizes the effect of estrogen and progesterone
Breast Anatomy
• The breast extends from : 1. clavicle superiorly.2. Mid-sternal line medially.3. 7th or 8th rib inferiorly.4. Anterior axillary line & axilla laterally .• Base is circular, either flattened or concave.• Separated from pectoralis major muscle by fascia,
retromammary space.• Axillary tail: prolongation of upper, outer quadrant of the
breast in axillary direction.
Breast Anatomy
Breast Anatomy
Nipple:– Level at fourth intercostal space– Small conical/cylindrical prominence below
center– Surrounded by areola – Pigmented ring of skin– Thin skinned region lacking hair, sweat glands– Contains areolar glands
Breast Anatomy
Areola: • Contains dark pigment that intensifies with
pregnancy.• Circular and radial smooth muscle fibers,
cause nipple erection
Breast Anatomy
Breast Anatomy
Three tissue types:1. Glandular epithelium Alveoli ductules (10-100 Lobules) lactiferous
ducts (15-20 Lobes) ampulla2. Fibrous stroma and supporting structures( Cooper
ligaments) it is a fibrous continuations of the superficial fascia, which span the parenchyma of the breast to the deep fascial layers.
3. Fat surrounds surface, fills spaces between lobes
Breast Anatomy
Breast Anatomy
Breast Anatomy
Breast Anatomy
Breast Anatomy
Breast Anatomy
– Arterial supply1. Internal mammary artery2. Lateral thoracic artery
– Venous return1. Intercostals2. Axillary vein (primarily)3. Internal mammary vein
Breast AnatomyArterial supply
1. Internal mammary artery2. Lateral thoracic artery
Breast Anatomy
Breast Anatomy
Lymphatic:- It is primarily to the axilla 75%.There are 6 axillary lymph node groups:(1) the lateral group along axillary vein. (2) the anterior group along lat. thoracic vessels.(3) the posterior or subscapular group.(4) the central group, embedded in fat in the centre of the axilla . (5) the subclavicular group (apical).(6) the interpectoral group (Rotter’s).- Only minor portion is to the internal mammary lymph nodes.
Breast Anatomy
Lymphatic Routes of Metastasis
1. From medial lymphatics to parasternal nodes then to mediastinal nodes
2. Across the sternum then to contralateral breast3. From subdiaphragmatic lymphatics to nodes in abdomen to
liver, ovaries, peritoneum
Subdiaphragmatic Lymph Channels
Channels to Contralateral Breast
Axillary Lymph Channels
Major Routes of Metastasis
Breast Anatomy
Breast Anatomy
Nerves:1. Long thoracic nerve2. Thoracodorsal nerve3. Medial pectoral nerve4. Lateral pectoral nerve
Congenital abnormalities
1. Amazia2. Polymazia3. Supernumerary nipples
Amazia
Polymazia
• Relatively common• Found along “milk line”• Most identified during
pregnancy/lactation• Most common in axilla• Not dangerous
Polymazia
Supernumerary Nipples
• More common than supernumerary breasts
• Found along milk line• May darken during
pregnancy• Not dangerous
Supernumerary Nipples
Supernumerary Nipples
Presentation
Symptoms: 1. Lump 2. Painful lump or lumpiness 3. Pain 4. Nipple discharge 5. Nipple change 6. Miscellaneous
Examination of the breast
Inspection The surgeon inspects the woman's breast with her arms by her side, with
her arms straight up in the air, and with her hands on her hips (with and without pectoral muscle contraction).
Inspection- skin, areolas , nipples, discharge – Symmetry– size– Erythema– Ulceration– Edema– Retraction– Scar– Dilated veins
Examination of the breast
Examination of the breast
Examination of the breast
• Inspection of the breast with arms at sides. B. Inspection of the breast with arms raised.
• C. Palpation of the breast with the patient supine. D. Palpation of the axilla.
Examination of the breast
Investigations of the breast
1. Mammography + xerography, Ductogram, Ductoscope 2. Ultrasound3. Magnetic resonance imaging4. Needle biopsy/cytology, tissue biopsy.
Triple Assessment • Clinical examination • Imaging ( Mammography/ US if < 35years)• Pathology (FNAC/Core needle)
Triple Assessment
Mammography
Mammography and xeromammography
Thermogram
• Transmission of detectable heat from the breast is nonspecific, and in malignant lesions results from the hypervascularity that frequently accompanies carcinoma.
Mammography
Ductogram
Ductogram
Ultrasound
Ultrasound Appearance Breast Masses
Simple Cyst Complicated Solid
Complex
Breast Cyst
Fibroadenoma
MRI
MRI
Ductoscope